Welcome to my blog. HIV prevalence is not a reliable indicator of sexual behavior because the virus is also transmitted through unsafe healthcare, unsafe cosmetic practices and various traditional practices. This is why many HIV interventions, most of which concentrate entirely on sexual behavior, have been so unsuccessful.

My objection to the illegal status of commercial sex work is that women who, for whatever reason, exchange sex for some benefit, need the protection of the law and access to health and other social services. At present, they do not have such protections and this is jeopardizing, not just their health and welfare, but also the health and welfare of others.

Sex work needs to be decriminalised so that women who are subject to abuse can report that abuse and claim the protection of the law. Women who have health problems need to be able to access health services. Then, even child prostitution and other issues can be addressed properly.

There are already laws about underage sex that criminalize the perpetrator, not the victim. There are already laws about rape and sexual assault, but few incidents are reported because of fear of stigmatization and mistreatment by the police and the legal system.

I sympathise with the author because no one wants to see people, least of all children, abused. But at present, adults and children are abused despite laws against commercial sex. It is the very laws against sex work that endangers the lives of the sex workers themselves, the victims of poverty, abuse, unemployment, crime and greed.

In order to get a job, keep a job, get promotion, get overtime or just get by in work, women often have to agree to sexual favours in exchange for things they should legally be entitled to. These phenomena are illegal, but that doesn't protect the victims because they can be accused of engaging in commercial sex work. The fact that exchanging sex for some kind of benefit is a crime means that the real crimes and abuses often go unreported.

The existence of the law does not prevent the crime from happening. The laws need to be properly upheld but that would require that police forces and other custodians of the law also be reformed. Despite the fact that there is already employment legislation that nominally protects employees, anyone suffering abuse is unlikely to seek redress from the law because of stigmatizing attitudes towards sex related crimes.

Opponents of decriminalisation of sex work argue that organised criminals involved in 'protecting' sex workers will benefit from such changes in the legal system. On the contrary, it is because sex workers currently are not protected by the law that they fall victim to pimps. Who is going to report human trafficking under current conditions? Not sex workers' customers, not the pimps and certainly not the 'competition', adult sex workers who are not (ostensibly) forced to work in the sex industry.

If people hate the idea of commercial sex work they would be better advised to advocate for employment, health services, social services and other benefits for those who currently have no alternatives for making enough money to survive. This would be the best way to promote the rights of children and adults who may otherwise be forced into the sex industry. The illegal status of sex work punishes the victims and exposes children to the dangers that it claims to protect against.

Of course, they may not be shocked. They may simply shrug their shoulders, because business, political and religious leaders have always been involved in the filthiest of excesses. There's never been much the electorate could do about that, except to shrug their shoulders.

Also implicated in the deals were former president Daniel Moi (it would be surprising if he were not involved in such a lucrative deal) and various other politicians, wealthy people and big businesses.

The amounts of land being discussed are only a fraction of the area of land that has been grabbed and if this is to be a typical story, the grabbers will be mainly wealthier people and organizations rather than poor people who have few other options for survival.

And just to make matters worse, Raila Odinga has tried to give the whole affair a tribal angle. Perhaps he's starting the next election campaign early.

They endorsed universal testing, for a start, which is particularly commendable because it is not part of the much hyped plan to test everyone and treat everyone found to be HIV positive. Not that I think that would be a bad thing to do, I just doubt the feasibility of such a huge and expensive undertaking at a time when fewer than 20% of people know their HIV status and the 30% of so HIV positive people on treatment may not be on treatment for long because of funding shortages.

But the more people tested, the better, whether there is treatment available or not. At least if people know their status they can take some measures to avoid infecting others.

The Summit also concluded that the Abstain, Be faithful, use a Condom strategy (ABC) is now obsolete, that it was a great strategy but that it had failed. I'm not sure what was so great about it if it failed but better late than never.

More worryingly, they came up with a strategy called SAVE or safer sexual practices, access to medication, VCT and Empowerment.

It's all very well to conclude that a strategy has failed and needs to be replaced but I wonder about the wisdom of replacing one costly slogan with another? Not that there is anything wrong with any of these aims, they are all good. But one of the problems with ABC was the dogmatism that went with it and the way it was indiscriminately shoved down the throats of everyone for so many years when it was clearly wrongheaded.

A single slogan with however many sub slogans is not what is needed. There are many conditions surrounding the transmission of HIV and they vary from place to place. Trotting out some slogan, no matter how enlightened it may seem in comparison to the moribund ABC campaigns, will simply not be appropriate for most contexts.

HIV is just one disease but its transmission is assisted by many different circumstances. People in a Nairobi or Mombasa slum have different vulnerabilities from commercial sex workers in smart clubs and tourist resorts. Men who have sex with men and women who have sex with women have different needs from long distance drivers, orphans and vulnerable children, single mothers in isolated rural areas, people on slave wages in export processing zones (EPZ) and underpaid workers on sugar or tea plantations.

The unwillingness to accept that HIV is transmitted in so many different contexts is one of the reasons why attempts to reduce its spread have been so unsuccessful. HIV is not just about sex, it's not just about commercial sex workers, intravenous drug users or same sex relationships, it's about so many different things. There is no single slogan that can be used and there is no single slogan needed. Marketing is to persuade people that they need something they may not need, good health and safe sex are not like that.

Some things do not work on commercial or economic principles and a really radical approach to HIV would reject the use of these failed approaches. A lot of money has been spent on expensive campaigns when what people need is good information and education. Marketing and the patronising slogans that go with it are no substitute for these.

Thursday, July 23, 2009

Why do the International Aids Society want us to believe that HIV funding has not distorted overall health funding and shifted attention from non-HIV issues while their partners at NAM want us to believe the opposite?

Spending on health, education, infrastructure and social services have been going down in Kenya since the 1980s. Many of these reductions were recommended by the World Bank and the International Monetary Fund (IMF) in the name of ‘structural adjustment’. Not that the Kenyan government was reluctant to reduce spending; the Moi regime (and the ones that followed it) couldn’t have cared less about public spending as long as the bulk of it went into the pockets of rich swindlers (otherwise known as business people and politicians).

It is true that large sums of money have been spent on HIV related treatment programmes and (far smaller sums) on HIV prevention programmes. But most of them had little or nothing to do with general health. Many of these programmes are standalone concerns, though they often tap into existing health capacity. Ok, they could have had some marginal, accidental positive affects and this requires investigation.

But in what way is this organization claiming that investments in HIV have contributed to health in general? There may be more health employees in the country but the number of GPs, nurses and health workers has not increased along with increases in the population. Worse still, many have been recruited (poached) to work with HIV, exclusively. Which “clinics and hospitals are being refurbished” with HIV funds, where are these “cadres of health workers” being mobilized, who are these health workers whose morale has been “greatly lifted”?

Was the purpose of the IAS Conference to get everyone together to have a great big feelgood session, so they could all pat each other on the backs? Maternal and child health has been disimproving since the 1980s, progress towards the Millennium Development Goals is negative. Who are these well paid and well qualified people trying to fool?

There’s a more credible article published by NAM (aidsmap.com), which also happens to be a partner of IAS. This article suggests that delivery of health care services has been seriously affected by the HIV/AIDS pandemic. This article is based on data (real data!) from the National Bureau of Economic Research at Princeton University. Maternal and child health has deteriorated since the mid 1990s in countries with high HIV prevalence. This deterioration is linked with a reduction in the number of trained health personnel and the fact that the pandemic “shifted health budgets and other resources towards caring for HIV patients”.

Personally, I prefer the article that is based on data. If the IAS produces data I’ll post it up here and people can make up their own minds what to believe.

Wednesday, July 22, 2009

I think HIV is an extremely serious issue and the disease has horrifying consequences. However, I think exceptionalising it has the effect of distracting attention from the very conditions that allowed HIV to spread as widely as it has done.

Health services, education, social services, infrastructure, governance, inequalities and attitudes towards sex and sexuality are some of determinants of HIV transmission. But improvements in all these areas are necessary, regardless of whether HIV is high, low, increasing or decreasing. In Kenya, from the eighties onwards, these issues have all been ignored. The arrival of HIV as a serious epidemic didn't cause them to be ignored but it certainly provided an excuse for putting them all on the back boiler. People need to know about safe sex, people need reproductive services and education, inequalities and prejudices need to be dealt with, but not just because of HIV. HIV is just one more sexually transmitted disease, it is just one more hazard arising from low levels of sexual health and sexual awareness.

I don't think the money going into HIV related programmes is wasted and if more money is needed, more money should be made available. But much of the money is being spent on goods and services from rich countries, very little is being spent in 'recipient' countries. These goods and services are being purchased regardless of whether that is the best strategy for HIV prevention and care programmes.

And very little is being spent on preventing new infections. Pharmaceutical and other countries are very keen to sell their overpriced products when it comes to treatment but not so keen about prevention. Yet unless the number of people becoming infected goes down, treatment will never be sustainable in the long run. Universal treatment is probably not even sustainable in the short run, for that matter.

With all due respect to Stephen Lewis, I think treating AIDS as exceptional has the effect of divorcing it from its context of serious and long term underdevelopment.

I can't comment on Lewis's accusations about other people in the AIDS field acting from motives of resentment and professional envy. I can understand if he is worried about levels of funding and how they may be affected by the current obsession with the global financial crisis. But I don't think it's justifiable to spend large amounts of money on pills for people who have no food or clean water. And I think that ridiculous situation arises in part from AIDS exceptionalism.

Communicable diseases (some of them, anyhow) get a lot more attention than other health issues but mortality from communicable diseases is only 25% of total mortality. A lot more people are dying of non-communicable conditions. More infants are dying now, more under fives are dying and more mothers are dying now, mostly from non-communicable conditions, than in the 1980s.

If Lewis believes that development funding is too low, I can agree with that. And certainly, HIV related funding has never been high enough. But there are many other diseases, communicable and non-communicable, that receive far less funding, if any. Worse still, people are dying from preventable and treatable conditions.

I don't think less money should be spent on AIDS; but I think greater amounts of money should be spent on programmes that improve people's lives more broadly rather than on programmes that concentrate narrowly on HIV, especially on sexually transmitted HIV. People's lives need to be transformed in every way and, for many, HIV is the least immediate of their problems.

When people have enough food and clean water for themselves and their dependents, when they have access to proper health services, when they receive adequate levels of education, when governance and laws actually protect people rather than increase their vulnerability, HIV treatment and care programmes may have some chance of being effective. Then also, people may be interested in protecting themselves and others against HIV.

There is a hierarchy of needs in developing countries and HIV is not at the top right now. Exceptionalising it won’t put it at the top but dealing with people's most urgent needs could raise its perceived importance.

Tuesday, July 21, 2009

Is it possible to eradicate a disease while ignoring its determinants?

Last December a new HIV prevention strategy was proposed (I covered it in this blog in December). It involved testing every sexually active person in a population for HIV (or as many people as possible) and treating anyone found to be HIV positive. The idea is that people on antiretroviral therapy (ART) have a low viral load, so they are unlikely to transmit HIV to others. A mathematical model of this strategy, using data from South Africa, indicates that it could be possible to almost eradicate HIV by 2050.

It has been widely recognised that it is better for HIV positive people to be diagnosed and put on treatment at an early stage in the progression from HIV to AIDS. This proposed strategy could have a lot of benefits for HIV positive people and their partners. As one of the authors of the proposal points out, "treatment is also about prevention". Preventing new infections should be made a much higher priority than it is now and this strategy should also enhance existing prevention efforts.

On the surface the strategy sounds great. The more people who know their status, the better. The more people on ART as early as possible, the better. The fewer people exposed to a high risk of HIV infection, the better. The modelling that the strategy is based on even gives some estimates as to what the costs may be. And the costs of aiming to eradicate the virus are certainly lower than continuing with current measures, where millions of people are becoming infected every year.

But countries with high HIV prevalence have been aiming for years to get as many people as possible to test, as often as they need to. In Kenya, only about 20% of people know their status. Some countries have been more successful in persuading people to test, others have been less successful. And only about one third of people requiring ART, people who would die without it, are already receiving treatment in Kenya.

But maybe the two arms of the programme could work, universal testing and universal treatment for everyone infected; or perhaps a high level of testing and treatment could be feasible. I would be very happy to see these goals being achieved. My only worry is that we may forget the sort of conditions that drive epidemics like HIV in the first place:

Widespread discrimination against vulnerable groups, such as men who have sex with men and commercial sex workers

Low levels of school attendance and low educational standards, including sex and sexuality education

Few and low quality social services, especially for vulnerable and needy people

Crumbling basic infrastructure, especially water and sanitation

High levels of corruption at most levels of society and poor governance

Low levels of employment and poor labour laws for those in employment

Low levels of nutrition and food security

High levels of economic inequality, inequality relating to inheritance, etc

High levels of gender inequality whereby females and the people they care for are particularly disadvantaged

This is not an exhaustive list and it may seem obvious that we shouldn't forget these things. But HIV is just one disease of many. And there is little point in preventing one disease in people when there are so many other things that cause so much injury or death. But more perversely, failing to deal with some of the structural problems listed above, such as health, education, inequality, discrimination or whatever, can result in failure to halt the transmission of HIV.

Even if everyone dutifully trots to the voluntary counselling and testing clinic every year and everyone found to be HIV positive receives ART, the problems listed above won't just go away. And as long as they continue to be ignored by the international community, as they have been ignored for many years, HIV will not be so easy to eradicate. It is not a 'standalone' disease, without a history and without determinants.

I don’t want to undersell the proposal so it’s worth pointing out that it is predicated on continuing with existing prevention programmes, but most of these also ignore the problems listed above! I am not opposed to the ambitious aim of testing and treating everyone, far from it. I just don't fancy our chances against HIV if we fail to address its determinants.

Monday, July 20, 2009

For some time it has been claimed that HIV testing plays a big part in reducing transmission of HIV because people who find out that they are HIV positive can take precautions to avoid spreading the virus. More importantly, it has been claimed that people who find out that they are HIV negative take steps to stay that way.

Well, of course it is good for people to be tested, whether they turn out to be positive or negative. Most people in most countries with a serious HIV epidemic don’t know their status. Those found to be positive can be given counselling, advice and, where required, medication. Those found to be negative can also be given counselling and advice.

But in South Africa, it has been noticed that many people who receive a negative result have subsequently increased their risky behaviour [http://www.plusnews.org/Report.aspx?ReportId=85033]. The goal to test as many people as possible is still perfectly valid but people need to modify their behaviour as a result of going through the testing and counselling process.

This sort of trend is not confined to South Africa. It has been noticed in Uganda that there was a 50% reduction in condom use among people who tested negative for HIV. In Zimbabwe, similar phenomena occurred and people also increased the number of their sexual partners, too.

The story is not all bleak because it is said that the opposite is true of young people testing negative in the US. They, apparently, go on to reduce their sexual activity and take other measures to avoid risky practices. That’s comforting because the US has the highest HIV prevalence in the developed world.

But it doesn’t answer the question of how to resolve the problems in South Africa, Uganda and Zimbabwe. Clearly, testing and counselling can’t be abandoned. And the mere knowledge that a negative test result can sometimes give rise to increased unsafe sexual behaviour should be of great help to policy makers and implementers.

But I think also that this is an important reflection of the fact that HIV is not just about sex. If you like, sex is not just about sex. People have sex for all sorts of reasons, aside from obvious ones, such as having babies, having fun, doing ones duty, etc.

The circumstances in which people live often determine whom they have sex with, how often, what kind of sex they have, how many partners they have, when they have sex and where they have sex. And many people are not in a position to choose or control all of these circumstances.

For example, a man who runs a community based organisation in Kibera slum in Nairobi points out that 66% of girls in slums enter the sex industry at some time, some at a very early age. Their economic and social circumstances play a big part in whether they can avoid becoming involved in the sex industry or not. Knowing that they are HIV positive or HIV negative may not play much part in how they behave after they have been tested.

Married women do not always have the option to demand that their partner uses a condom, even if they know that their husbands have other partners or may already be infected with HIV or other sexually transmitted infections.

Many Kenyans live in poverty, many are short of food all or most of the time, clean water and adequate sanitation are non-existent for most people, electricity and other modern conveniences are just not readily available. Given these circumstances, people face many hazards already. Unsafe sex may just be one hazard of many.

It’s not the sex itself that threatens people but a whole array of circumstances that determine people’s sexual behaviour, their relative risks and vulnerabilities.

It is probably beyond the scope of voluntary counselling and testing services to provide Kenya with the means to develop its health, education, infrastructure and social services. But these matters need to be dealt with in the forthcoming National AIDS Strategic Plan, whenever the government gets around to publishing it. The last one (and the one before) concentrated on a narrow range of HIV prevention programme possibilities.

Let’s hope the next one takes a broader outlook and takes into account the connections between people’s sexual behaviour and the circumstances in which they are forced to live.

Thursday, July 16, 2009

Flicking through articles on the BBC website, I was struck by an article about a type of emergency contraception called the E-pill, currently being marketed in Kenya. Not that it’s strange that emergency contraception should be marketed in Kenya, just that it is being marketed by Population Services International (PSI). They receive tens of millions of dollars in donor funding every year to promote safe sex so that people can protect themselves from unplanned pregnancies and sexually transmitted infections (STI), including HIV.

Emergency contraception is taken by people who haven’t used planned contraception or for whom that contraception has failed. What I find odd is that PSI should market this product without also pointing out the things that the E-pill does not protect you from. Surely this organisation is supposed to be marketing methods, not products? Is it naïve to expect them to be more concerned about broad outcomes rather than narrow indicators? These E-pills are likely to appeal to those who don’t use condoms, the very people who need to recognise the dangers of unprotected sex aside from unplanned pregnancy.

The director of PSI who is interviewed is right in pointing out that marketing contraceptive products to people does not necessarily result in them having sex, having more sex, starting to have sex earlier or having more risky forms of sex. But it is a struggle to promote safe sex as a way of avoiding several inherent dangers that sexually active people face, pregnancy being just one of them.

If young people are being exposed to STIs and HIV, unplanned pregnancy may even be the least of their worries. In fact, people who become pregnant and contract HIV at the same time will probably have their HIV status diagnosed as soon as they attend an antenatal clinic. If they don’t get pregnant, their HIV status may not be diagnosed until they eventually do get pregnant or until they become very ill. At this stage, they will probably have transmitted HIV and other STIs to other people.

One of the problems with marketing a single-issue programme as a means of protecting against HIV, such as male circumcision, is that it ignores the issue of pregnancy and, indeed, several STIs that are not prevented by it. It is senseless to sell safe sex as a means of avoiding just unplanned pregnancy or just STI or HIV infection. Family planning and safe sex marketing must involve all the issues. And PSI is supposed to be concerned with all the issues, not just one at a time.

One of the oddest aspects of this story is that it is not even permitted under Kenyan law to advertise emergency contraceptives in the first place. But because PSI is American and funded by donor funding, the whole thing is ok as far as the Kenyan government is concerned.

I agree that emergency contraception is, as claimed, preferable to botched abortions. It is preferable to unplanned pregnancies. But I think emergency contraception could appeal to the very people that PSI should be targeting: people who don’t want to use planned contraceptive methods, such as condoms.

PSI talks of making ‘the markets work for the poor’ in its mission statement and lists one of its core values as ‘[t]he power of markets and market mechanisms to contribute to sustained improvements in the lives of the poor’. Perhaps the organisation is a little too market driven to claim truly to be working for the benefits of poor people. It seems to me that the markets are working for PSI very well, thank you very much.

Wednesday, July 15, 2009

I'm trying to figure out if the Kenyan government is peopled by idiots or if they have genocidal tendencies. Perhaps both are true of them. Millions of Kenyans are facing food shortages, water shortages and all the longer term consequences that go with these catastrophes. Perhaps as many as one third of the population, maybe even more, do not have enough to eat or drink and they do not have the means to purchase enough food or drink for themselves or their dependents.

So what do the Kenyan government do? They lease a huge piece of land, said to be 40,000 hectares, to the Qatari government so they can grow food crops for Qataris. This is good fertile land; as to how many Kenyans will be displaced, with or without compensation, in order to accommodate the food security of a population that is neither starving nor poor, we are not told.

So, not only is the government leasing land where they could be growing food for Kenyans, but the industrial scale agricultural production that will be employed by the Qataris will require as much water as the area can provide, perhaps more. The two things, food and water, the lack of which is threatening the health and probably the lives of so many Kenyans, are being handed over to a country that should be well able to find an alternative solution for their own problems.

What is Kenya getting in return? A 2.5 billion dollar port in Lamu. The port in Mombasa is not even working to full capacity, the infrastructure surrounding it is in pieces but the Qatari government is offering a brand new port in Lamu. Lamu and the Tana River, where the industrial scale agriculture will take place, are areas of great natural beauty. They are also areas of great ecological importance. It seems hard to believe that a proper assessment has been made of the needs of Kenya's people and the impact that these two major projects will have.

If you look at the Tana River area and the island of Lamu on a map of Kenya you will notice how few roads there are in this region. Travelling overland from other parts of Kenya involves circuitous routes. Will the Qatari government funds also stretch to roads connecting the region to the rest of the country? It seems unlikely. But once these projects are underway, there may not be many reasons left to go to the areas anyway.

Already in the Tana River area, various countries lease land to grow things like sugar cane, to be used as a biofuel. These other countries are not even worried about producing food on Kenyan land, they just need something to stick in their car. Suddenly, people all over the world are 'helping Africans to develop their agricultural potential'. It's not as if Kenyans even gain anything from such projects. Large scale agricultural production is not labour intensive and most of the people living in these areas have been bought off for a pittance. The claims that significant numbers of jobs will be created are just the usual rubbish.

I don't want to sell Kenyan politicians short; they did appeal to international donors for food relief. I hope these donors will ask how deals like the one with the Qatari government will help alleviate starvation in Kenya. The country doesn't need food relief, it needs to use the assets it has got properly. Leasing them to a country that doesn't need them for an asset that Kenya doesn't need is hardly the answer.

People in the Kenyan government have denied that the deal has gone ahead and say it was only discussed. However, land is already being used in Kenya to produce biofuel crops for other countries, I have met people involved in biofuel crop production. The 40,000 hectare figure above is dwarfed by some of the other deals being discussed. Other large scale agricultural projects have been implemented by foreign operators and have caused large scale destruction, displacement of people, loss of livelihoods and other problems that are not reported in the foreign press. Only certain sorts of internal displacement are deemed worthy of note by the foreign press and instances where rich countries benefit can safely be ignored.

Countries other than Kenya have been involved in betraying their people in similar ways, Tanzania, Madagascar, Ethiopia, Sudan, Ghana and Mali, for example. No doubt, the respective political situations in some of those countries make it pretty easy to get land at knock down prices. And Qatar is not the only country to profit from such betrayal, the list also includes other Gulf States, the US, China and South Korea.

There are several questions that governments and others involved in such deals do not address. When large scale agricultural production obviates the need to employ most of the people who live in an area sold or leased out, where are these unemployed and landless people supposed to go? Cities already have far more people than they have housing, infrastructure, water, sanitation or food for. Rural unemployment in other areas is also very high and most people depend on some way of subsisting rather than having formal jobs. Where will they go and what will they do?

When these other countries have used up their 5 to 25 year lease, what will happen with the land then? Presumably it will be pretty useless. The ecologies of the areas being leased will have been destroyed, water tables will have been lowered, soil will have been leeched, both soil and water will have been poisoned by fertilizers, herbicides, pesticides and other pollutants. Unless it is redeveloped for some other purpose, it will be useless. Right now, areas like Lamu attract a lot of tourists (when the civil disturbances are not too numerous) but there will be little attractive about these places once the factory farmers have done their work.

It sounds as if Kenyans could end up with even less than they have now and for many, that's not a lot.

The bill's definitions are ambiguous enough to be interpreted in a way that makes generics indistinguishable from fakes. This could result in generics not being allowed into the country. As generics can be up to 90% cheaper than the branded versions, this could result in people being unable to afford to continue treatment.

Representatives of pharmaceutical companies and pharmaceutical companies themselves deny that the anti-counterfeiting act would have such a result and deny that they will try to block generics from coming into the country. However, generic medicines have already been held up in European ports and this Kenyan act will only make it more likely that delays will occur.

It is not in the interest of most pharmaceutical companies to have cheap generic versions of drugs being used instead of their expensive, branded versions. Of course, some of them could, and probably do, produce their own generics. But these companies are answerable to their shareholders and anything that threatens profits, regardless of the cost, is not likely to be too popular.

Besides, the pharmaceutical industry is very good at persuading powerful people to promote their interests. In the US, the industry spends several hundred million dollars a year on lobbying. This figure doesn't include other costs, such as advertising and research. These companies know they can make a profit from generics. but they know that the profit is many times higher if they can kill as much trade in generics as possible.

The anti-counterfeiting legislation relies on people associating generics with fakes. Fake goods blight the everyday lives of Kenyans, some even threaten their health. But ironically, it is the extortionately high prices of branded goods that makes the fake goods industry so profitable!

Generics are not fakes. In fact, the very existence of generic versions of ART drugs will make it feasible for most, or even all, HIV positive people to be able to avail of treatment when they need it.

At present, a small percentage of people who need ART are receiving it. That percentage may get smaller as the present economic climate gets worse. But if generics are pushed out of the market there will never be enough money made available to provide ART for all who need it.

The industry is very rich and will continue delaying and blocking things indefinitely as they continue to extort enormous amounts of money from sick and dying people. I hope the people in Kenya succeed in their challenge to the anti-counterfeit legislation, for their benefit, for the benefit of Kenyans and for the benefit of citizens of other developing countries who are also being pushed by the pharmaceutical industry to pass self-serving laws.

Monday, July 13, 2009

Uganda is presently discussing an anti-homosexuality bill. Same sex relations are already against the law in Uganda (although same sex relations between females is not mentioned). The bill being discussed doesn't just ban same sex relations, it also bans publishing and distributing literature on homosexuality or 'advocating' for it.

There seems to be an assumption, which is far from uncommon, that people who have same sex relations actively 'recruit' people who would, if left alone, have remained heterosexuals. I find that assumption peculiar. It suggests that if those politicians, journalists, religious leaders and others who rail against same sex relations, could have turned out to be homosexuals themselves if they had been subjected to the influences of such 'recruitment'.

The minister for 'ethics and integrity' was interviewed on the subject and he seems to lump together "homosexuality, pornography, prostitution, human sacrifice, drug abuse, embezzlement and witchcraft" and feels that these are symptoms of society becoming permissive. Perhaps this minister should go back to school and learn to make very basic distinctions between what are very different concepts. But, sadly, I think he is just lacking in the sort of simple logic needed to engage in everyday life.

The issues he lumps together range from rare but horrendous crimes to common but undesirable ones. But he doesn't give any justification for his belief that homosexuality should be seen as a crime. Same sex relationships usually involve consenting adults. Not all sexual relationships involve consent and this is rightly seen as a crime, whether same sex or heterosexual. Pornography has many victims, as do prostitution and drug abuse.

Human sacrifice and witchcraft (aside from the mere suspicion that someone is a 'witch'!) are subjects that I am not able to comment on. But I should hope that human sacrifice is always punishable by law and that witchcraft is if it results in the breaking of laws.

But as for embezzlement, I wonder why the minister mentioned this crime. I can see why it is a crime but he seems to be worried about Uganda becoming a permissive society. Permissive societies do not permit embezzlement, not that I know if, anyhow.

The effect of criminalizing same sex relationships will give rise to discrimination against people engaging in them and against those thought to engage in them. It will increase the risk of crimes being committed against them. Surely, Mr Minister, you are opposed to crime and you would not wish to put forward legislation that will encourage it?

When it comes to preventing HIV transmission, criminalization of same sex relationships will make it more difficult to protect men who have sex with men (MSM). MSM are very vulnerable to being infected with HIV and are more likely to transmit it than those engaging solely in heterosexual relationships.

But this means that it must be made possible for MSM to be open about their sexual practices. If they are not open about their sexual practices it will not be possible to target this group with appropriate HIV reduction programmes. They will do everything they can to remain invisible, they will not be able to seek medical attention safely, they will not be protected by the law; they will become even more vulnerable than they are now and they will represent a greater obstacle to reduction of HIV transmission.

But I don't want this to be an argument for decriminalizing same sex relationships just because it helps control HIV. I simply don't think having sex with a person of the same gender should be seen as wrong. Of course it's wrong if one party doesn't want to take part but that should already be outlawed by laws against rape and sexual assault.

Clearly, prostitution and any kind of sex in exchange for goods, services, favours or whatever, is being entirely different. But criminalizing transactional sex (instances of it that are branded as 'prostitution', not all transactional sex, that would be impossible!) also faces the same problems as criminalizing same sex relationships, listed above. People involved in transactional sex, the ones this minister proposes punishing, are vulnerable. He is proposing making them far more vulnerable than they are already.

This minister for 'ethics and integrity' seems to have a serious problem with sex and sexuality and I don't think he is the most appropriate person for this ministerial brief. But perhaps he can learn; who knows? Perhaps his problem is with people who he sees as 'not like him'? Maybe he is a very praiseworthy man, morally, and thinks that everyone should be like him. But then he may be in for a surprise if he looks around his country, especially at his fellow leaders, political leaders, religious leaders, society leaders, etc.

The minister claims that people engaging in same sex relationships are abusing the rights of the majority. He is quite wrong, same sex relationships do not abuse any rights. On the contrary, he is trying to legalize the abuse of minorities. As for how many people in Uganda engage in same sex relationships? The present homophobic climate means that most people will not be open about their sexuality or about their opinion about the sexuality of others. The effects of his homophobia run deep and are long lasting.

As for the minister's call to religious leaders to 'fight immorality', he may wish to gen up on the record of some religious institutions when it comes to matters of sex and sexuality, even prostitution, embezzlement, pornography and other serious crimes. The trouble with people as perfect as this minister seems to be is that he may be in a very small minority himself.

But I would also question why people who don't want to use condoms, for whatever reasons, would risk an operation that may not even give them the level of protection they need. Are people queuing up to be circumcised, perhaps, because they don't want to use condoms and they think being circumcised will obviate the need for these? The article claims that health services are "struggling to meet demand" for circumcision, which certainly doesn't inspire confidence in health services that were already stretched beyond breaking point. But apparently this campaign also tells people that circumcision only provides partial protection and that they need to continue to use condoms.

So if they don't bother getting circumcised but just use condoms instead, they would achieve higher levels of protection from HIV than if they go for circumcision and don't bother using condoms any more? Well, as I said, the campaign also involves persuading people to use condoms but we know that this is a very hard sell. In fact, condoms protect against a number of sexually transmitted infections and unplanned pregnancies, something circumcision doesn't do so well. So of course, the combination of circumcision and consistent condom use should be a good bet. But it sounds as if a mass male circumcision campaign would cost a lot of money and only benefit a relatively small part of the population (unlike condom-use campaigns, sex education, gender equality, better legislation, etc).

For a start, we knew long before the 80s, before HIV had ever been heard of, that people who don't have enough food or water will die. We knew that sick and unhealthy people are more susceptible to disease, any disease, than healthy people. We knew that poorer people face more health risks than richer people. We knew that less well educated people were likely to have worse health than educated people. We knew that people without alternatives would take risky jobs and take more risks in their jobs. We knew that trade policies that only benefit rich countries at the expense of poor countries will make poor countries poorer (for peat's sake, it's a tautology!) and we knew many, many other things that we failed to act on. We are still failing to act on them. These issues are all, either directly or indirectly, related to HIV transmission.

Worse still, international financial institutions spent the 80s, 90s and 2000s giving loans to developing countries on condition that they reduced spending on health, education and other social services, especially infrastructure spending and personnel costs. The HIV prevention programmes that have been implemented since HIV has been identified, such as they were, required the very structures that were being dismantled and continue to be dismantled to this day!

MMC is just one possible HIV reduction programme out of many. But like all other HIV reduction programmes, it will run up against the same problems, such as lack of adequate health services, low levels of health education and adult literacy, poor infrastructure, few social services, etc. If MMC can prevent the millions of infections claimed by experts, such campaigns will require a lot more than training hundreds of masked scalpel wielders. They will need well funded health, education and social services. These latter criteria may or may not have been within reach in the 80s but now, so many years later, they are not even on the development agenda.

I'm not dismissing MMC as one possible intervention out of many. Once the controversies have been cleared up, and there are many, it may have its uses. I'm just wondering why there seems to be so much pressure to spend a lot of money on an intervention that could only benefit a relatively small minority of Kenyans, at best. About 75% are already circumcised. I also think that MMC is a pretty high risk intervention to implement in a country that has so many other health needs and so little health capacity.

The links between environmental conditions with acute respiratory infections and the links between water and sanitation with water borne diseases, for example, have been recognised for a hell of a lot longer without a damn thing being done about them. And a lot more people die from these than from HIV/AIDS. Given that the powers that be are not usually interested in cost effective measures that save many lives and vastly increase the health of many others, why would they be interested in measures that could, at most, affect a relatively small number of lives?

Why should this particular ‘missed opportunity’ receive so much attention and funding, and why now? Is it really true to say that ‘millions of lives could have been saved’ had MMC been introduced long ago. And if it is true, what about the millions more that could have been saved by attending to the many, far more serious areas of development? There seems to be something inherently more political than humanitarian about MMC.

My aim is not to criticize Kenyan university students here, though they really should take note of their vulnerabilities. My aim is to question the country's overall strategy to reduce transmission of HIV. For a start, most money that has been spent on HIV has gone to those who are already infected, on treatment and care programmes. That's fine, as far as it goes. But doesn't the Kenyan government want to cut the number of new transmissions so they can afford to continue to treat and care for those already infected? But even the money that has been spent on HIV prevention doesn't seem to have been spent on effective programmes. Ok, we hear so much about condom social marketing and various programmes that involve slogans and celebrities and sports and various ‘feelgood’ factors. But which of these programmes have been effective? Well, all of them, if you ask their proponents. But why, then, is HIV transmission still so high?

Well, of course, I don't know the answer to that. But I do know that in Kenya many people do not get enough basic education and that many do not have access to basic health care or other social services. Sex education requires recipients to have some basic educational background for it to mean anything. And sexual health requires a good level of general health. So, dealing with education and health in general would probably help specific HIV related health and education programmes to be more effective.

But that doesn't answer the question of why the people who receive enough education to reach university are also not responding to HIV prevention programmes. Well, sex is just not a popular topic for many people; politicians, church leaders, teachers and parents, for example. Even well educated people have very mixed ideas (some true, some confused) about sex and HIV transmission. It's almost as if their sexual behaviour, then, remains completely independent of and unaffected by the various HIV prevention programmes going around.

I would suggest that the exceptionalisation of HIV has not helped in this respect. HIV is presented to people as something separate from their overall health, as something unprecedented, something that requires emergency measures. But HIV it is not exceptional in the sense that it infects more people or kills more people than other diseases. It is a virus, one of many, that happens to be spread sexually (mainly). Given that most young people have sex, many of them are vulnerable. HIV is not a short term emergency, it is an endemic condition in Kenya and many other developing countries in the world. It is not something that can be eradicated in a short period of time.

And it will certainly not be eradicated by separating this one virus from every other health issue. On the contrary, this is one of the things that can lead to people viewing HIV as something 'other', something that affects people who have been 'bad'. Sex is not bad, it is part of human behaviour, always has been and always will be. Yes, people can take precautions and make sure they only indulge in ‘safe sex’. But they don’t seem to be responding very well to the finger wagging, moralising and frankly medieval prevention campaigns that can be found in Kenya. And that’s hardly surprising.

I was in a London HIV clinic yesterday and people all looked furtive, as if they were going someplace they shouldn't be going. Even in a country that likes to think of itself as permissive and liberal, where sex and sexuality are easier to discuss than they are in East Africa, HIV and other sexually transmitted infections are still treated differently. But at least here in the UK, people have better access to education and information pertaining to health. Health services of any kind, particularly sexual health services, can be pretty remote from the day to day lives of most Kenyans.

I think many people just ignore the messages they hear. Their sex life is their business and they consider themselves to be careful and in control. Try telling most car drivers that they are doing something wrong; they see themselves as being in control and if something does go wrong it's got to be someone else's fault. HIV has been too much associated with things that people feel are not relevant to them, such as commercial sex work, men having sex with men, intravenous drug use, etc. Perhaps HIV programmes are not working very well because they have this 'undesirability' factor built in to them.

Sex plays a big part in the lives of most people. Therefore, HIV is just one issue that relates to sex and just one negative issue, for that matter. Sexual health is as much a part of people’s overall health as nutrition, say. HIV needs to be put in a context where it can be seen as relevant to the lives of ordinary people in Kenya, whether they are well educated and comfortably off or less well educated and poor.

The religious and political posturing, that seems to be so influential when it comes to HIV programming, is killing people. Just as sex is a part of people’s lives, sexual health needs to be seen as a part of their overall health.

Monday, July 6, 2009

The Kenya Anti-Counterfeit Law, which fails to distinguish between fake drugs and generic versions of drugs, has been signed for some time. People may have expected a country that depends on donor funding for much of its health programmes, especially HIV related programmes, to welcome a supply of cheap generic drugs from other countries that are struggling to create markets, such as Brazil and India. But it seems that the Kenyan government has done just what big pharmaceutical companies would have liked.

Now that the bill has been signed, there is pressure on the government to implement it. The pressure is coming from lobby groups and interested parties, so it remains to be seen exactly what the effect will be. No doubt other governments who are unable to provide their people with adequate health services, not to mention food, education and other social services, will copy the Kenyan government, with a lot of help and encouragement from the same lobby groups.

One of the reasons it is worthwhile making fakes is that branded goods are too expensive. When antiretroviral drugs were developed, with the help of massive amounts of public funding, the prices were set so high that there was little chance people in developing countries, where most HIV positive people lived, could afford them. Over the next few years, pharmaceutical companies lobbied their governments, and anyone else who would accept their bribes, to make aid money available for their overpriced drugs. Eventually aid money was provided, billions of dollars of it, and the pharmaceutical companies didn't have to reduce their prices very much at all.

Now, there is a recession. Donor money is in short supply. Countries like Uganda, Zimbabwe, Zambia, South Africa and Kenya are barely able to keep a minority of people who need antiretroviral drugs on treatment. This situation is only going to get worse as the numbers of people needing treatment goes up and funding becomes scarcer. Developing countries need to do anything they can to help HIV positive people live a relatively healthy life. Generic drugs could go a long way to helping developing countries achieve this goal.

So why do countries like Kenya seem hell bent on frustrating the efforts of producers of generic drugs? Their efforts to prevent HIV transmission have mainly met with failure and tens of thousands of people are newly infected every year. Tens of thousands more are in need of treatment but are unable to access it because of lack of funding. What kind of incentive have these lobby groups given to the Kenyan government to pass such destructive legislation? I think that is the sort of question Kenyan citizens should be asking their local representatives.

Let big multinationals and pharmaceuticals fight their own battles and if they are worried about counterfeiters, they should lower their prices. Their products are not expensive to produce and much of the costs they claim to pay are paid for by taxpayers in various donor countries. They are not advocates for health or human rights and they should not be able to interfere in the welfare of people in developing countries. We need to be protected from what is effectively a bunch of mercenaries, wielding any weapon they can to screw profits from the poorest and most vulnerable people.

And the idea that these mercenaries are worried about countries losing tax revenue and about their citizens being duped is just bunkum. Citizens everywhere are being duped by multinationals and big pharma all the time. It's just that some people are less able to pay for the consequences. These thugs do not have the right to dictate how governments should run their country and they do not have the right to bribe or coerce them to do their bidding, either. If a legitimate government tried to do what they are doing, people may object, but it seems that multinationals can do things that governments cannot.